As Charlie’s heart failure worsened, his twig-like fingers searched over his chest and he asked, “Doc, can you show me where my heart is?” Confused, I pointed just left of his sternum and inquired, “Why do you ask?” He explained he feels like he is drowning and uttered “I grew up on a farm Doc and if things get worse a shotgun to the heart is quick, but can be messy!”

Charlie appeared younger than a man in his late 80s, white trimmed beard, crystal blue eyes and a baseball cap. As a former military pilot and a retired truck driver, he told you like it was. There was no depression. In fact, I found him always jovial with a zest for life. Charlie fired his cardiologist. He said, “Doc, I will not see any other doctor but you.” He was always ready to share deep lessons for living life at full throttle, on his own terms.

He refused all aggressive interventions and referrals to prolong his life. For years when I mentioned checking his cholesterol he would flash a wry smile, “Why Doc? I'm still gonna eat what I want and do what I want and not take any pills.”

I explained to Charlie that in Oregon we have the Death with Dignity Act, that allows those who have less than 6 months to live to die peacefully, with a self-administered lethal medication, prescribed by a physician. He refused to be referred to Hospice. On one visit, I explained that most states don't have physician-assisted dying. In my residency training in Florida, they rumored that one of our beloved cardiologists had died differently. After receiving the terrible news of incurable metastatic pancreatic cancer, he had sailed into the sunset with Percocet and tequila, on his own terms. Charlie loved that story.

I had forgotten that I shared this story with Charlie over a decade ago. His steel trap memory forgot nothing. Whenever his heart failure worsened, he would let me know his suffering by saying, “Hey Doc, I'm ready for that Percocet and tequila”. Then he would take a stronger dose of lasix and avoid salty fried foods, and he was back golfing with his buddies. The dance between salt and lasix continued for many years. 

Charlie gave my daughter an old electric keyboard when she was 9 years old. When he found out she was attending a prestigious music college in New York, he smiled. I reminded him that the keyboard “played instrumental” in her music career and he chuckled with vigor. Charlie loves a good pun.

Again, Charlie refused all referrals and consults. I recommended hospice or Death with Dignity. Charlie refused. I recommend home health care. Charlie refused. Instead, he insisted, “you are my Doc. I don't need to see anyone else.” He would be down with fluid in his lungs and I would tweak his diuretic pills and he sprang up golfing again with his buddies.

Charlie lived to golf and make others happy. Even in his late 80s with end-stage heart failure, he would walk a majestic world renowned short par 3 course, Fiddler’s Green, with no help. Every Saturday, he met two old buddies that were also former military and in their 80s as well. Peter had end-stage lung disease, from smoking 2 packs per day since he was in the womb. Patrick had severe diabetes with neuropathy so bad he could barely hold the golf club. He also had retinopathy that made him legally blind and he could not see the golf ball. Naturally, Patrick was the best golfer of the threesome. 

One day, I received an invitation to join Charlie, Peter, and Patrick in their threesome. How could I refuse? 

The four of us were warming up, and I asked Charlie, “What is the most important thing in golf to improve your game?” Surely, he would say the swing or the new driver technology. His response was surprising, but not unexpected. He gripped and then ripped his driver 90 yards and it rolled onto the green for a birdie putt. Then he looked at me with a sly smile and said, “Balls!” Indeed, in the game of life as in golf, one must fearlessly give it your all, for the best result in any endeavor. That's the secret Doc, “Balls to the wall or else you stall.” The starter at the first tee who eavesdropped on the conversion flashed us a beautiful gap toothed grin.

That day was magical and after we played 9 holes I suggested we play the back 9 and all three eagerly agreed. Charlie would later tell me it had been many years since they all had walked 18 holes but they were excited and honored that I had joined them. The honor was all mine.

In a recent clinical encounter to refill his meds, Charlie had looked at my face and blurted out, “Doc, why do you have a divot on your forehead?” Tears began streaming down my face as my abdominal muscles ached because indeed the divot on my forehead was comical. I had to explain that a mole was removed and the dermatologist created a deep divot to remove it all. The more apt golf metaphor was a high handicapper hit it fat, based on the huge chunk of flesh gauged from my dome.

Thankfully, as Charlie’s end-stage heart failure worsened, he reluctantly agreed to hospice care. He also agreed to the Death with Dignity program and could have aid in dying medication available if things got to the “Percocet & tequila” level.

As Charlie was getting his affairs in order he appeared more youthful, vibrant and happy than I have ever seen him. He was in his mid 90’s dying of heart failure and yet he genuinely appeared happier than ever. I asked Charlie what was his “secret” to living such a joyful life and achieving exceptional longevity and he immediately responded without hesitation, “Let go of all the cargo.” Cargo represents all the material accumulation of stuff that weighs us down and makes us unhappy. Charlie’s body, his last remaining cargo which was breaking down, was his last material possession that he was preparing to let go. He could recite Shakerpeare by heart and mentioned it was time to “shuffle off this mortal coil”. I mentioned if he needed one last refill of his sleeping pill. He thought for a long moment and and with a smile quotes Hamlet, “To sleep---perchance to dream. Ay, there's the rub! For in that sleep of death what dreams may come…”

Charlie came to see me and my staff one last time to say his goodbye. When my staff checked him in, he slowly took off his oxygen and shuffled into my office without help. He said, “I think I am ready to take the “adios medicine.” We both knew this was our last visit, and we savored every moment, sharing golf stories, catching up on family, and telling jokes. Charlie, being a history buff, asked me if I was familiar with the famous line from Washington to Hamilton of “Dying is easy, young man. Living is harder.”  Of course I was familiar with the classic line from the musical Hamilton. He shared that dying has been hard for him because of the politics of finding a consulting physician and the exorbitant cost of the lethal medication for aid in dying. He blurted, “Doc, it seems like only the rich folks can afford this medication to die with dignity.” We both commiserate on the tragic fact that all 50 states allow our companion animals to die with dignity yet 40 states in America it is illegal to end the pain and suffering of a terminally ill human being. 

I went through the ritual of listening to his heart and lungs and checking his blood pressure, even though there would be no intervention. As I was searching my brain for the right things to say… What do you say to a dying person who has only a few weeks to live? What do you say to an atheist, a farmer and a tough guy but the nicest, sweetest person you'll ever meet? He interrupted me, “Don't forget my B12 shot Doc!” My mind returned to the clinical encounter and our ritual. At the end of our appointment of almost an hour, I said, “Charlie, it has been my honor to take care of you. You are my favorite patient. What am I going to do now?”

Charlie looked at me with watery blue eyes and said, “You have been the best doctor and have given me the greatest care.” After a brief pause, I got a strong feeling that Charlie was trying to tell me that his dying was not my fault. It was his time to let go of his cargo.

As I escorted Charlie out of my examination room through the portal of the doorway, he smiled, “Adios, Doctor.” He had shuffled his skeletal frame a mere two feet past me, slowly and carrying his portable oxygen, I felt the urge to stop him. He turned around and our eyes met with a smile. My voice cracked, “Charlie, you left a divot on my heart.” After a long pause, the corners of his mouth wobbled and then he shuffled down the hall for the last time.

In the following days, I wondered whether Charlie had pain and suffering in the end. What method did he use to end his life?  The “adios medicine” with Death with Dignity and aid in dying, or the cocktail of Percocet and tequila, or the farmers shotgun to the heart approach?

A week later, I received a call from a volunteer at End of Life Choices. With a soothing voice, she informed me he passed away peacefully. She also informed me that in the corner of his room was an old loaded double-barrel shotgun… We were all thankful for the “adios medicine.”

Disclaimer: The medical stories shared by the author are based on real patient encounters. All patient identifiers and medical facts have been removed and altered to such a degree that you are reading a work of fiction. Therefore the stories shared are merely to entertain you. However, for the astute reader you may find powerful and profound lessons for living. These messages of universal truth should not be construed as medical advice, but feel free to use them as free Cuban soul spice to live your truth.