with 250k on it I would say the next step is a backpressure test, if a cat is clogged this would possibly explain the issue if everything else is good,
you can get a kit or make one from harbor freight
you stick the fitting in one of the front 02 sensor bungs and start it up, should read no more than 5 psi (max)
I had a clogged cat and would get unexplained misfires and knock retard like a mofo, but at idle it was fine. it had got so bad it was causing lean codes and misfires, knock retard.
had no power, you could drive like gramma and it was fine, but if you went to say pass someone on the highway with some pedal it had nothing gutless wonder. anything at higher speed caused flashing cel, gutted the 3rd cat and it has been perfectly fine since.
not saying this is your issue, but it is worth checking, especially if the history of the truck is unknown, might cost you $30 for one from harbor freight.
other possibilities, chaffed wire on the coil/injector harness, if the wires are resting on anything and rubbing it can wear thru on the bottom part