Background Calciphylaxis is a rare and poorly understood complication of end stage renal disease (ESRD) that causes a complex pain difficult to manage in the acute hospital and hospice environment. Its management is further confounded by the symptom burden of ESRD and the challenges of facing the extremely poor prognosis associated with this condition.

Aim We aim to share our experiences in treating this condition using a holistic, cross-specialty approach. We would also like to suggest our guidance in managing the physical and psychosocial symptoms of calciphylaxis whilst exploring advance care planning (ACP) in ESRD in a short time frame.

Method We present a case of a patient newly diagnosed with calciphylaxis on a background of ESRD. The patient was managed by the hospice palliative care team with input from the renal physicians in both the acute hospital and hospice environment, spanning a period of two months from acute presentation to death. The case illustrates the impacts of various methods used in treating the patient’s symptoms. There is also a review of the evidence and guidelines for the use of opioids in ESRD as well as the guidance on ACP in ESRD.

Results We found that a cross-specialty approach is key to managing the symptoms of calciphylaxis and ESRD even when dialysis is discontinued. A variety of analgesics and formulations were required in treating the associated ischaemic pain. In utilising the multidisciplinary team, a comfortable death was achieved whilst placing the patient’s choices at the centre of their care.

Conclusions In treating the complex symptom burden and unusual presentations of ESRD, a close working relationship between the palliative medicine and renal team is essential. ACP conversations are desired by these patients but can be infrequent in reality and should be instigated earlier and repeatedly throughout their patient journey.