“Another phone call about my bloods — just tell me straight. And I’m not having an operation.”

Primary hyperparathyroidism is the commonest cause of hypercalcaemia in primary care: a raised albumin-adjusted calcium with a PTH that is raised or inappropriately normal. NICE NG132 (2019) advises measuring PTH when adjusted calcium is 2.6 mmol/L or above on two occasions (or 2.5 or above with suspected primary hyperparathyroidism), and not excluding the diagnosis if PTH is in the upper half of the normal range. Refer people with confirmed primary hyperparathyroidism to a specialist with expertise in parathyroid surgery if they have symptoms, end-organ disease (renal stones, fragility fractures or osteoporosis), or an albumin-adjusted calcium of 2.85 mmol/L or above. Parathyroidectomy is the only cure and has a high success rate; the specialist will exclude familial hypocalciuric hypercalcaemia (urine calcium), arrange imaging and assess bone density. For people who decline or are unsuitable for surgery, monitoring and, in some circumstances, cinacalcet are options. In primary care: review drugs (thiazides reduce urinary calcium excretion; lithium causes hyperparathyroidism; stop calcium and vitamin D supplements unless deficient), measure vitamin D and replace deficiency, advise good hydration, and do not restrict dietary calcium. Safety-net for severe hypercalcaemia (vomiting, confusion, abdominal pain, dehydration), which needs same-day care. Symptoms such as tiredness, thirst, constipation, aches, low mood and poor concentration may be due to hypercalcaemia and can be mistaken for grief or ageing. The communication skill is exploring a pre-emptive refusal: understanding the bereavement behind it, giving honest information, respecting autonomy, and agreeing a step he can accept, such as hearing the specialist’s options.