• Cancer
• Pain
• Pharmacology
• Drug administration

Escalating pain and agitation in the terminal phase of illness can be challenging. Here, we present the case of a young adult patient with multiple-relapsed and refractory acute myeloid leukaemia with painful intracranial disease and terminal agitation. The patient required long-term opioid treatment for pain management and was therefore opioid-tolerant. The pain and agitation escalated in the final days of life and the response to intravenous opioids and benzodiazepines was inadequate. An intravenous infusion of clonidine was commenced and rapidly escalated over the subsequent 2 days with good effect.

Prior to the terminal phase, the patient’s symptoms of headache and bone pain were managed with; oxycodone MR 60 mg two times per day, pregabalin 150 mg two times per day, amitriptyline 50 mg at night, mirtazapine 45 mg at night, oxycodone 10 mg intravenous 2 hourly as required. The ‘as required’ analgesic requirement was often in the range of 60–80 mg/24 hours oxycodone administered intravenously; the intravenous route was used because of immunocompromise and thrombocytopaenia.

Symptoms deteriorated on day 27 of the admission, with severe headache and agitation, which responded well to 15 mg …