A 'River' Runs Through It

An unconventional memoir focuses on the end-of-life journey.

Richard S. Cohen is the author of The Smooth River: Finding Inspiration and Exquisite Beauty During Terminal Illness, in which he recounts his wife Marcia’s empowering final days. BookLife spoke with Cohen about writing the book that honors his spouse both in life and in death.

This book defies characterization. It’s part memoir, part love story, part guide to navigating the medical system, part how to make the most of our time while we can. But, in a fundamental way, the work is a handbook on how to approach death and how to approach life.

Marcia received her diagnosis out of the blue. As a crisis manager who represented famous people, she was used to being the calm within the storm for others. But, obviously, this news set our minds spinning. While we were committed to exploring every medical avenue that we could, Marcia realized she could either succumb to societal norms that would mean living her remaining days reduced to a fighter who is judged by whether she won the battle or not, or she could accept that life was finite, and that medicine does not have all the answers. Marcia wanted to be seen as being more than her condition, and this distinction was critical. She wanted to live in contentment and beauty, what we came to refer to as “Smooth River,” an analogy that conveyed how we wanted to be treated, as well as a philosophy and mindset that we wanted others to adopt. By coming to terms with the end, we would be able to imbue this precious time with potential and exquisite beauty.

The Smooth River approach is the opposite of what most people go through at the end of life with a terminal disease.

Yes, it truly is. Marcia did not want her legacy to be whether she “won the battle” against pancreatic cancer. It was stage 4, and we knew the odds. What she wanted was to leave a legacy that was meaningful to her and to those she loved. Our medical plan balanced treatment with optimism and realism. We balanced our medical plan with a life plan that gave structure to our days. Netflix movies by candlelight, walks by the river, long drives, and daily scheduled time in the sunroom, where Marcia could talk about anything that was on her mind. Also, it was important to Marcia that she help others, and being able to focus on that helped get it off ourselves. Marcia wanted to spend her remaining time doing for others.

While the benefits of adopting of the Smooth River mindset are clear to see, it also must have been a huge challenge. You write in the book that “attitude is everything” and encourage readers to “choose order, not chaos.” That’s a tall order at such a difficult time.

We certainly didn’t start out with the Smooth River mindset. But it got better. The first four days, before we were able to see any medical professionals, were head-spinning. We were in crisis. But, as we saw oncologists and other cancer patients, we began to work through the maze. We realized we were not in isolation We gradually discovered a different perspective that was in contrast to the rigid tunnel approach others adopted, where the mantra was “fight, fight, fight.” Believe me, there were a lot of tears, times wheren we lost it and lamented getting the short end of the stick. But, in coming to terms with reality and truth, there was an exquisite beauty, and Marcia was able to live out her final wishes. She was determined to invest her time in certain projects, to live life the way she wanted. She assessed it, processed it, and made the best of it.

In the book, you share an email you sent to friends and family after Marcia’s diagnosis, outlining the approach you and Marcia were adopting. How did people react?

When people hear such news, they look down on the ill person without even knowing it. We wanted people in the river with us and to be as normal as possible. Marcia had lived a full life, and, while we didn’t like her situation at all, we wanted to make Marcia’s time beautiful and do the things she liked to do. People were inspired by Marcia’s uplifting approach, and she made it easy for people by accepting her situation. Imagine someone who is ill reflecting that it was okay. Her sense of calm and order seeped through to those around us, and, as a result, she had a wonderful, rewarding experience with others, the opposite of the norm. This is one of the main messages of the book. People need to step back and look at things through a wider-angle lens. This will without a doubt lead to more comfort, satisfaction, and peace, and result in better memories for the family and a more positive legacy.

What advice do you have for patients and for doctors when dealing with terminal illness?

Patients and doctors should communicate openly, and patients should be treated with empathy and as a whole person, not just an illness. Unfortunately, doctors are predisposed to always being rushed, so they need to be reminded that the patient has a life outside the exam room. This levels the playing field a bit and humanizes the relationship.

What are the most important messages you’d like readers to take away from the book?

There are several prevailing themes. First, a patient’s life should be defined by the entirety of their life, not simply by their condition. Secondly, it’s important to recognize that there’s so much value in coming to terms with life being finite. We all have a choice of whether our remaining days are fulfilling, spiritual, or gratifying, or to endure chaos that doesn’t take advantage of whatever time remains in the hourglass. Lastly, define how you want to be remembered.