• Pain
• Peripheral vascular disease
• Terminal care
• Drug administration

Ischaemic limb pain can be challenging to manage with a relatively poor response to conventional analgesics. In the following case presentation, good analgesic results were achieved with a peripheral nerve block infusion, but the question then became one of which setting could manage her analgesia and how to achieve the patient’s stated preference about preferred place of care and death.

The patient, in her 80s with multiple comorbidities, presented to hospital with pain and was diagnosed with a critically ischaemic leg. An attempted angiographic procedure and endarterectomy were unsuccessful and complicated by myocardial infarction. The patient declined the option of amputation, following which she was referred to the hospital palliative care team. At that point, her analgesia regimen consisted of regular paracetamol, oral oxycodone modified release 30 mg two times per day and gabapentin 600 mg three times a day. She had tolerated morphine poorly with respiratory depression so had been switched to oxycodone.

She had a supportive family and lived with her husband. Over the following week, her oxycodone was titrated to 50 mg two times per day and gabapentin to 900 mg three times a day but pain remained poorly controlled, so amitriptyline 10 mg nocte was added. A couple of days later, she became feverish without a clear source of infection and became more confused, which the team suspected was due …