My first palliative care death.

James was a 70-year-old man with metastatic lung cancer; that was, he had lung cancer that had spread. He'd been having a lot of pain and was admitted to the palliative care unit for pain management and medicine optimisation before discharge home.

His wife was a lovely lady. Both of them were great to chat with as I clerked James in. I told him we needed to take a one-off blood test to see his liver and kidney function so we could decide what meds were best for his pain. After three attempts, I couldn't get any blood. My consultant told me that was fine, we'd try again tomorrow as it was no major urgency.

The next morning, I failed again. At last, early afternoon, we managed to get blood.

Potassium returned at 7 (normal range is 3.5-5.0). His eGFR (a measurement of kidney filtration rate -- for the healthy average person, it's >60) was 9. His previous eGFR was in the mid 50s, a few months back. I was stunned. Why had his kidney function dropped from almost-normal to non-existent over just a few months?

It didn't matter at that point. Hyperkalaemia (potassium that was too high) was a medical emergency as it put his heart at risk of irregular rhythms and death, so I put in a cannula, repeated the bloods, started IV fluids, and called my senior.

My senior arrived, took a read of his history, looked at his bloods, and told me to stop.

"He's dying."

I didn't understand. Hyperkalaemia was correctable. You give fluids, you give nebulised salbutamol, you give insulin and dextrose infusion. You encourage the kidneys to pee out the excess potassium. If needs be, we can dialyse (assuming the patient can withstand the volume of blood being filtered in dialysis).

"But it's because he's reaching the end of his life that his kidneys are shutting down. That's the cause of his hyperkalaemia. You can't treat that."

My senior went in, alone, to break the news to James. He and his wife took it calmly. I didn't know how -- I still don't -- but it was agreed we would withdraw all active treatment and just treat his pain. No more blood tests. No more scans. No resuscitation. A dignified, peaceful death, on his terms.

I hid in the supply cupboard and cried. James was going to die soon, we knew that, with his diagnosis. But he didn't come here to die. He came here for symptom management and then home. His granddaughter was due to be born any day now. His daughter-in-law didn't want to announce the baby's name because she wanted it to be a surprise. He didn't know the baby's name yet.

He died peacefully with his wife at his side six days later. His granddaughter was born the day after; the baby's parents (James's son and daughter-in-law) didn't want her to be born on the same day Granddad died.

His granddaughter's name was Daisy. His daughter-in-law whispered the name in his ear before he died, so he got to know, even if he never got to meet Daisy.